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Li et al. BMC (2020) 20:293 https://doi.org/10.1186/s12886-020-01556-0

RESEARCH ARTICLE Open Access Trifocal diffractive intraocular implantation in patients after previous corneal refractive laser surgery for Qiu-Mei Li1†, Feng Wang2,3†, Zhe-Ming Wu4, Zhen Liu5, Chuan Zhan6, Bing-Heng Chen7, Jing Sima7, Knut Stieger3* and Shao-Wei Li1,2*

Abstract Background: With the difficulties in IOL power calculation and the potential side effects occurring postoperatively, multifocal IOL implantation after previous corneal are rarely reported especially for the trifocal IOL. Herein we report the clinical observation of trifocal IOL implantation in patients with previous myopia excimer laser correction. In this study, a multi-formula average method was performed for the IOLs power calculation to improve the accuracy. Visual and refractive outcomes were analyzed, and the subjective quality of patients’ life was evaluated by questionnaires survey. Methods: This retrospective case series included patients with previous myopia excimer laser correction who underwent femtosecond laser assisted and trifocal IOL (AT LISA tri 839 MP) implantation. Follow-up was done at 1-day, 1-month and 3-month to assess the visual outcomes. Outcome measures were uncorrected distance, intermediate and near visual acuity (UDVA, UIVA, UNVA), manifest refraction, defocus curve, and subjective quality of vision. Results: Twenty-one Eyes from sixteen patients (14 eyes with previous laser in situ keratomileusis and 7 eyes with previous photorefractive keratectomy) were included. Mean postoperative spherical equivalent (SE) at 3-month was − 0.56 D ± 0.49 SD, wherein, 10 eyes (47.6%) were within ±0.50 D of the desired and 19 eyes (90.5%) were within ± 1.0 D. Mean monocular UDVA, UIVA and UNVA (logMAR) at last visit were 0.02 ± 0.07, 0.10 ± 0.10, and 0.15 ± 0.11 respectively. Three patients (19%) reported halos and glare in postoperative 3 months, two of them needed to use spectacles to improve the intermediate visual acuity. Fifteen patients (94%) reported a satisfaction score of ≥3.5 out of 4.0, without any difficulty in daily activity. Thirteen patients (81%) did not need spectacles at all distances, while the other 3 patients (19%) used spectacles for near-distance related visual activity. Mean composite score of the VF-14 questionnaire was 95.00 ± 7.29 out of 100. Conclusions: Trifocal IOL implantation after myopia excimer laser correction could restore good distance, intermediate visual acuity and acceptable near visual acuity, and provide accurate refractive outcomes as well as high spectacles independence rate. Keywords: Trifocal IOL implantation, , LASIK, PRK, Myopia, Aphakic refraction technique

* Correspondence: [email protected]; [email protected] giessen.de †Qiu-Mei Li and Feng Wang contributed equally to this work. 1Beijing Aier-Intech Eye Hospital, Beijing 100021, China 3Department of Ophthalmology, Justus-Liebig-University, 35385 Giessen, Germany Full list of author information is available at the end of the article

© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Li et al. BMC Ophthalmology (2020) 20:293 Page 2 of 9

Background 839MP) implantation in eyes with previous corneal re- Corneal refractive laser surgery that began in the 1990s fractive laser surgery for myopia. In this study, a multi- has been well developed and widely applied in ametropia formula average method was performed for the IOLs correction for millions of patients. Over time, these pa- power calculation to improve the accuracy. The visual tients eventually become presbyopic or cataractous and and refractive outcomes were analyzed, and patient satis- are more demanding for the freedom from glasses [1]. faction and subjective quality of vision were also evalu- To that end, a further refractive procedure is required ated using VF-14 questionnaire and another short such as multifocal intraocular lens (IOL) implantation. questionnaire concerning negative visual symptoms. With the continuous renewal and improvement of surgi- cal equipment and implantation material, multifocal IOL Methods implantation after has been increasingly This retrospective case series included patients who had applied in clinical practice and effectively restored visual previously undergone LASIK or PRK for myopia and acuity, thus becoming an alternative of refractive proced- underwent femtosecond laser assisted phacoemulsifica- ure [2–7]. Recently, some studies have shown that the tion and trifocal IOL (AT LISA tri 839MP, Carl Zeiss multifocal IOL implantation could be safely and effi- Meditec AG, Jena, Germany) implantation in AIER ciently used for patients who had previously undergone Group’s Eye Hospitals (Beijing Aier-Intech Eye Hospital, corneal refractive laser surgery [8–11]. Obviously, the Guangzhou Aier Eye Hospital, Chongqing Aier Eye Hos- modern cataract surgery combining an intraocular lens pital, Wanzhou Aier Eye Hospital and Shenzhen Aier Eye implantation gradually becomes a refractive procedure Hospital) from January 2017 to May 2019. Ethics Commit- rather than a treatment only for blindness. However, tee approval by the Institutional Review Board of the Aier due to the difficulties in IOL power calculation and the School of Ophthalmology of Central South University was potential side effects occurring postoperatively such as obtained for the present study protocol that adhered to the glare or other visual acuity problems, only few reports of tenets of the Declaration of Helsinki. Written informed the clinical observation of multifocal IOL implantation consents were obtained from all the enrolled patients. after previous corneal refractive laser surgery exist, and The inclusion criteria consisted of eyes (1) that had even less for the trifocal IOL implantation. surgery indication for cataract surgery without any con- Currently, bifocal IOLs are used as the major multi- traindications of ocular surgical therapy in the preopera- focal IOLs with only near and far focus and hence pro- tive examination, (2) with corneal ≤1.5 D vide good distance and near visual acuity and moderate and the angles of Kappa and Alpha both being < 0.3 mm, intermediate vision. As a newly emerging product from and (3) had no complications of posterior capsular rupture IOL multifocality technological development, trifocal or zonular dialysis during the cataract surgery. The exclu- IOLs were designed to provide three useful focal dis- sion criteria included eyes that (1) had decentered ablation tances (near, intermediate and far) and thus improve the (decentration > 0.5 mm), corneal scar, retinoschisis, haze, intermediate vision without impairing distance and near myopic retinopathy, retinoschisis or visual acuity [12–16]. An increasing number of reported after myopia excimer laser correction, (2) with corneal clinical observations have demonstrated the positive out- astigmatism ≥1.5 D or irregular astigmatism ≥0.3 μm, and come after trifocal IOL implantation and recent system- (3) had inflammation, or other diseases that atic reviews also showed the advantages of trifocal IOLs might affect the multifocal IOL implantation. in comparison with bifocal IOLs [17, 18]. Within this trend, trifocal IOLs would become a reliable alternative Patient examinations option for cataract patients with previous corneal re- Enrolled patients all underwent preoperative ophthalmo- fractive laser surgery in the foreseeable future. So far, logic examinations including corrected distance visual there are few studies reporting the visual outcomes of acuity (CDVA), UDVA, manifest refraction, retinal visual trifocal IOL implantation after previous corneal refract- acuity, intraocular pressure, ocular A and B-scan ultra- ive surgery. Wang et al. recently reported on a trifocal sonography, non-contact specular microscope, optical IOL implantation in eyes with nuclear cataract about 15 coherence tomography (OCT) and ray tracing aberrome- years after myopic LASIK surgery, which restored vision try. The retinal visual acuity was assessed with Lambda efficiently [19]. Chow and co-worker thereafter reported 100 retinometer (Heine, Germany). The axial length, a case series of trifocal IOL implantation for post- keratometry and anterior chamber depth were measured myopic LASIK patients providing a good visual outcome using the LenStar LS900 (Haag Streit, Switzerland). at both near and distance vision [20]. To further confirm The postoperative measurements at 1-day, 1-month the clinical effect of trifocal IOL implantation after pre- and 3-month included CDVA, UDVA, UIVA, UNVA, vious corneal refractive surgery, we herein present a and the subjective manifest refractions (spherical equiva- retrospective case series of trifocal IOL (AT LISA tri lent) as well as their changes. Through-focus monocular Li et al. BMC Ophthalmology (2020) 20:293 Page 3 of 9

logMAR acuity (defocus curve) was also measured. The who underwent bilateral implantation and the eyes with spectacle independence rate, satisfaction, and visual a large difference (> 1.0 D) in the IOL power calculations symptoms were recorded at 3-month postoperatively using the 4 formulas, a modified aphakic refraction tech- with the Visual Function index 14 (VF-14) question- nique was applied based on the reported aphakic refrac- naire, which provides an index of functional impairment tion procedure by Dr. Mackool [29]. At first, the cataract in patients with cataract [21, 22], as well as another removal was performed without IOL implantation. 1 Day short questionnaire concerning negative visual symp- later, manifest refraction examination was performed for toms. VF-14 was translated into Chinese [23] and based the lens power calculation followed by the IOL insertion. on 14 uncorrected vision–dependent daily activities, All the two-staged-procedure surgeries were performed scoring each item with regard to the degree of difficulty in the same fashion after obtaining patient’s consent. as follows: no difficulty (4 score), a little difficulty (3 After 1 week, another would be performed. score), moderate difficulty (2 score), quite difficult (1 Postoperative treatment included one drop of score), or impossible to perform the task (0 score). Items tobramycin-dexamethasone eye drops every 2 h for 3 were not included in the scoring if patients could not days, afterward four times per day until 2 weeks, and perform the activity for reasons other than vision- then three times per day for another 2 weeks; and one related. Scores on all activities were averaged, and the drop of levofloxacin eye drops four times every day for mean score was then multiplied by 25. The resulting 1 week; pranoprofen and sodium hyaluronate eye drops VF-14 score ranged from 0 (worst functional impair- were administered as appropriate. ment) to 100 (no disability) [24]. The short question- naire with regard to some negative visual symptoms Statistical analysis commonly observed after cataract surgery, such as halo, Statistical analysis was performed using Microsoft Excel. glare, was recorded by the correspondent surgeon. Mean (± SD) was reported for continuous variables. Normal probability plots and Kolmogorov-Smirnov and Surgical technique Shapiro-Wilk tests were used to check the normality of All the surgeries were performed combining femtosec- data in SPSS software. Pre- and post-UDVA, pre- and ond laser-assisted phacoemulsification and intraocular post-CDVA outcomes were compared with the t test. lens implantation by experienced surgeons. For the eyes Nonparametric tests were used to evaluate differences with corneal astigmatism between 0.75 D and 1.5 D (6 within groups. Differences were considered statistically eyes), femtosecond laser-assisted corneal relaxing inci- significant when the P value was less than 0.05. sion was performed for correction. Preoperatively, the surgeons used tropicamide to maintain pupil dilation in- Results traoperatively. Under topical anaesthesia, This study comprised 21 eyes of 16 patients (five men, (diameters were all set as 5.2 mm), lens fragmentation 31.3%). The demographics of the study population are and corneal relaxing incisions were performed subse- summarized in Table 1. The mean patient age at the quently using the LenSx femtosecond laser (Alcon La- time of IOL implantation was 48.5 ± 8.9 years (range, 36 boratories, Inc., Fort Worth, Texas, USA). to 66 years). The mean time gab between the refractive Phacoemulsification was then performed using standard surgery and cataract surgery is 13.2 ± 4.3 years. Eleven ultrasound technique. In case of the patients with high (68.7%) and five patients (31.3%) underwent unilateral myopia who underwent femtosecond laser surgery, both and bilateral implantation respectively. No complications anterior and posterior capsules were thoroughly polished developed intraoperatively. No further laser enhance- to reduce the risk of capsule contraction. The trifocal ment was performed. The mean logMAR of UDVA and IOL (AT LISA tri 839MP) was implanted in the capsular CDVA were 0.83 ± 0.48 (range, 0.22 to 1.70) and 0.37 ± bag using an injector. The residual ophthalmic viscosur- 0.30 (range, 0.00 to 1.00), respectively. The mean axial gical device was removed, and the position of the lens length was 27.70 mm ± 2.20 (range, 25.13 to 33.00 mm). was adjusted. All incisions were hydrated and the pa- The mean preoperative spherical equivalent (SE) was − tients’ conjunctival sac was treated with dexamethasone- 5.49 D ± 5.75 (range, − 18.75 to + 1.37 D). tobramycin ophthalmic ointment. For lens power calculation, a multi-formula average Refraction method was performed, in which 4 formulas of Hagis-L After lens extraction and IOL implantation at 3-month, [25], Barrett True K [26], Shammas No-History [27] and the mean SE was reduced to − 0.56 D ± 0.49. Figure 1a ray-tracing methods [28] setting the target refraction as shows the change of mean SE at the three follow-up in- postoperative emmetropia were used. The implanted tervals (1-day, 1-month and 3-month). The histograms IOL power was the average of the calculated results of the postoperative refractive accuracy are presented in from all 4 formulas. For the first treated eye of patients Fig. 1b. Ten eyes (47.6%) were within ±0.50 D of the Li et al. BMC Ophthalmology (2020) 20:293 Page 4 of 9

Table 1 Demographics of the patients before IOL implantation Item Number or Mean ± SD (range) Number of eyes (N) 21 Number of patients (n) 16 Sex (male/female, n/n) 5/11 Years after refractive surgery 13.2 ± 4.3 (3, 21) Refractive surgery procedures (numbers of eyes), (percentage) PRK 7 (33.3%) LASIK 14 (66.7%) Symptoms (numbers of patients), (percentage) Bilateral 5 (31.3%) Unilateral 11 (68.7%) Eyes with modified aphakic refraction technique 11 (52.4%) Mean age (Years) ± SD (range) 48.5 ± 8.9 (36, 66) Mean pre-UDVA (logMAR) ± SD (range) 0.83 ± 0.48 (0.22, 1.70) Mean pre-CDVA (logMAR) ± SD (range) 0.37 ± 0.30 (0.00, 1.00) Mean pre-SE (D) ± SD (range) −5.49 ± 5.75 (−18.75, + 1.37) Mean axial length (mm) ± SD (range) 27.70 ± 2.20 (25.13, 33.00) Mean keratometry (D) ± SD (range) 38.36 ± 2.27 (34.34, 41.94) Mean power implanted IOL (D) ± SD (range) 17.64 ± 3.87 (8.0, 23.00) IOL intraocular lens, LASIK laser in situ keratomileusis, PRK photorefractive keratectomy, UDVA uncorrected distance visual acuity, SE spherical equivalent, pre- preoperative desired emmetropia and 19 eyes (90.5%) within ±1.0 D the defocus of 1.50 D (with a visual acuity of 0.34 log- at postoperative 3 months. In contrast, only 3 eyes MAR), all visual acuities tested at other defocus diopters (14.3%) were within ±1.0 D preoperatively (Fig. 1c). Fig- were better than 0.23 logMAR, maintaining a functional ure 1d shows the attempted versus achieved SE refrac- range of visual acuity. tion. At 3-month follow-up, the overall rate of overcorrection was 0%, while the overall rate of under- Questionnaires correction was 9.5% (2 eyes). Tables 3 and 4 summarized the results of the VF-14 and supplementary questionnaires. Three patients (19%) re- Visual acuity ported halos giving the least mean scores of all items in The mean postoperative CDVA was 0.00 ± 0.05 logMAR, VF-14 questionnaire as 3.42, 3.50 and 3.64 respectively, the mean postoperative UDVA was 0.10 ± 0.16 logMAR two of them needed to use spectacles to improve the at the first day postoperatively (Table 2). All the surgery intermediate visual acuity. Thirteen patients (81%) did eyes (21 eyes, 100%) achieved postoperative CDVA ≥20/ not need spectacles at all distances, while the other three 25, while the percentage for UDVA ≥20/25 was 76% (for patients (19%) reported the need to use spectacles only the postoperative cumulative Snellen visual acuity, see for the near-distance related visual activities such as Fig. 2a). Additionally, the mean postoperative UNVA, reading books and doing handwork. Fifteen patients UIVA and UDVA at 3-month were 0.15 ± 0.11 logMAR, (94%) reported a satisfaction score of ≥3.5 out of 4.0, 0.10 ± 0.10 logMAR and 0.02 ± 0.07 logMAR respect- without any difficulty in daily activity. ively. All obtained monocular visual acuity data at the last visit are summarized in Table 2. Discussion Previous studies of eyes after corneal refractive laser sur- Defocus curve gery have focused primarily on monofocal IOLs [26, 30– Monocular defocus curve at 1-month (Fig. 2b, results of 32] and bifocal IOLs [8–11]. In our study, we present 20 eyes) showed best visual acuity (0.02 logMAR and this retrospective case series of trifocal IOL (AT LISA 0.13 logMAR) with defocus of 0.00 D and − 3.00 D, tri839MP) implantation in patients who underwent a simulating distances of 4 m and 33 cm. In the range be- previous corneal refractive laser surgery for myopia. The tween the peaks, the curve transited smoothly and AT LISA tri839MP used in our study is a monolithic dif- reached the bottom as 0.14 logMAR at − 2.50 D. Besides fractive trifocal intraocular lens which is made of Li et al. BMC Ophthalmology (2020) 20:293 Page 5 of 9

Fig. 1 Refraction outcomes. a Changes of mean SE at the three follow-up intervals (1-day, 1-month and 3-month); b Histograms of the postoperative refractive accuracy; c Percentages of eyes within ±0.5 D and ± 1.0 D of emmetropia; d Spherical equivalent attempted versus achieved collapsible hydrophilic acrylate (25%) with a hydropho- extensively counselled regarding the possible side effects bic surface. Its optical zone has a diameter of 6.0 mm, a of the treatment such as night glare, halos and decreased total diameter of 11.0 mm, and a four-turn intraocular contrast sensitivity, even the possibility of deteriorated lens with a zero angle. The intraocular lens combines a visual quality after a refractive corneal laser procedure. bifocal diffraction range from 4.34 to 6.00 mm, and a tri- The final decision was made based on their wishes to re- focal diffraction range (over 4.34 mm) on the front sur- store vision and hence becoming independent of face of the lens, which is achieved based on the spectacles. asymmetrical light split, that is 30, 20, and 50% of the in- Intraocular lens implantation in eyes with previous coming light is split at near focus, intermediate focus, corneal refractive laser surgery is full of challenges due and distant focus respectively. It was developed to over- to the difficulty in IOL power calculation [30, 35, 36]. come the photic phenomena and the poor level of inter- To date, some reported IOL power calculation methods mediate vision of traditional multifocal IOLs [33] and have been used for IOL implantation in eyes with previ- has already been demonstrated to have good outcomes ous corneal refractive laser surgery providing relatively of visual acuity at near, intermediate and far distance accurate outcomes [31, 37, 38]. However, obvious hyper- and high postoperative satisfaction [34]. Patients were opia is often observed postoperatively [39, 40]. For the

Table 2 Monocular visual acuity (logMAR) Parameter Preoperative Postoperative at 1-day P Postoperative at 3-months Mean ± SD Range Mean ± SD Range Mean ± SD Range CDVA 0.37 ± 0.30 0.00, 1.00 0.00 ± 0.05 −0.08, 0.10 < 0.001 \ \ UDVA 0.83 ± 0.48 0.22, 1.70 0.10 ± 0.16 −0.08, 0.52 < 0.001 0.02 ± 0.07 −0.08, 0.22 UIVA \ \ \ \ \ 0.10 ± 0.10 0.00, 0.30 UNVA \ \ \ \ \ 0.15 ± 0.11 0.00, 0.40 Li et al. BMC Ophthalmology (2020) 20:293 Page 6 of 9

Fig. 2 Visual outcomes. a Postoperative cumulative Snellen visual acuity; b Monocular distance-corrected defocus curve given in logMAR at 1- month postoperatively (N = 20) lens power calculation in the present study, a multi- improvements were made based on the previous investi- formula average method was applied which has been de- gation and to pursuit accuracy in IOL power calculation. scribed and proven to be accurate in our previous study In the refraction outcome, the mean postoperative SE [41]. Additionally, corneal edema and intraocular pres- was reduced to − 0.56 D ± 0.49 while Chow’s study re- sure (IOP) changes could also affect the intraoperative ported a − 0.92 D ± 0.76 with a significant myopic shift calculation of lens power. A modified aphakic refraction [20]. In addition, 10 eyes (47.6%) were within ±0.50 D of technique was used in our study for the first operative the desired emmetropia and 19 eyes (90.5%) within ±1.0 eyes of patients who underwent bilateral implantation D at postoperative 3 months in our study. All our cases and the eyes with large difference (> 1.0 D) in the IOL were targeted for emmetropia, and the results were simi- calculated results from multi-formulas. The time gap be- lar to Vrijman’s study with a lower percentage of eyes tween the cataract removal and manifest aphakic refrac- with ±0.50 D. This is because most of the patients in- tion was extended from 30 min (Dr. Mackool’s cluded were preoperatively high myopia with either less procedure [29]) to 1 day. This extension has been dem- spherical equivalent (9 eyes, 43%, with < − 6.00 D) or onstrated to increase the stabilization of refraction in longer axial length (16 eyes, 76%, with > 26.00 mm). It is our previous observation, and hence reduce the error consistent with Vrijman’s finding that results were less giving a more accurate calculation result. Both these predictable in eyes with myopia greater than 6.0 D [10].

Table 3 Three-month postoperative responses to visual function questionnaire (VF-14) itemsa Item Score (mean) ± SD Score multiplied by 25 Spectacle independence rate Reading small print 3.06 ± 0.77 77 81% Reading a newspaper or a book 3.63 ± 0.62 91 88% Reading a large-print book or numbers on a telephone 3.88 ± 0.34 97 100% Recognizing people when they are close to you 4.00 ± 0.00 100 100% Seeing steps, stairs, or curbs 4.00 ± 0.00 100 100% Reading traffic, street, or store signs 4.00 ± 0.00 100 100% Doing fine handwork like sewingb 3.36 ± 0.50 84 87% Writing checks or filling out forms 3.81 ± 0.40 95 100% Playing games such as bingo, dominos, card games, mahjong 4.00 ± 0.00 100 100% Taking part in sports like bowling, handball, tennis, golf 3.94 ± 0.25 98 100% Cooking 3.94 ± 0.25 98 100% Watching television 3.88 ± 0.34 97 100% Driving during the day‡ 4.00 ± 0.00 100 100% Driving at night‡ 3.50 ± 0.76 88 100% aScore scale: 4, no difficulty; 3, a little difficulty; 2, moderate difficulty; 1, quite difficult; 0, impossible to perform; b N = 15; ‡ N=8 Li et al. BMC Ophthalmology (2020) 20:293 Page 7 of 9

Table 4 Results of the short questionnaire concerning negative visual symptoms in postoperative 3 months Negative visual symptoms in postoperative 3 months Number of patients Percentage Halos 3 19% Glare 3 19% Flare 00%

The results of vision outcomes show a statically sig- myopia (preoperative spherical equivalents are − 7.60 nificant improvement after surgery. The mean postoper- and − 12.37 respectively). It seems that the capsule of ative CDVA and UDVA was 0.00 ± 0.05 and 0.10 ± 0.16 high myopic patients is larger, and the stability of intra- (logMAR), respectively. Both these two outcomes are ocular is slightly worse compared to normal pa- significantly better than preoperative outcomes (Table 2, tients. The position and functional deviation of P < 0.001). The mean value of postoperative CDVA intraocular lens might lead to bad visual symptoms such agrees with the result of Chang and co-workers (20/19, as halos. In the other hand, the preoperative symptoms Snellen Vision) by converting into Snellen Vision [11]. of halos or glare, and the status of the fellow untreated To accurately evaluate the visual outcomes of trifocal eye from patients who was performed unilateral surgery, IOLs after previous corneal refractive surgery, the mon- might affect the postoperative visual outcomes and ocular UDVA, UIVA and UNVA were recorded at last interfere with the clinical analysis of the efficiency of tri- follow up in our study, and the mean values (logMAR) focal IOL implantation. Unfortunately, all the informa- were 0.02 ± 0.07, 0.10 ± 0.10 and 0.15 ± 0.11 respectively. tion had not been recorded preoperatively. Nevertheless, However, among the few reports using multifocal IOL the total spectacles independence rate is 81% (13 pa- implantation, only Chang’s study recorded the same vis- tients), and those patients without halos or glare all have ual outcomes wherein the mean UIVA was 0.22 ± 0.15 scores better than 3.67. Overall, the questionnaires sur- (logMAR) as higher than the value we observed. These vey showed good quality of life postoperatively in the results indicated that the trifocal IOL implantation for current study. the cataract patients who previously had underwent my- The limitation of this study was the small sample size. opia excimer laser correction, could restore good dis- Undoubtedly, a larger sample size would be more helpful tance, intermediate visual acuity and acceptable near to shed light onto the efficiency of trifocal IOL implant- visual acuity. ation after previous corneal refractive laser surgery for As an important indicator for the vision over the en- myopia. However, due to the uncertain side effects of tire range, defocus curve was also recorded in this study. multifocal IOL implantation after previous corneal sur- In 2015, Jonker et al. compared the defocus curves after gery, the number of patients who balanced the side ef- trifocal IOL implantation with that after bifocal IOL im- fects by their demands for becoming independent of plantation in cataract patients [13]. In their comparison, spectacles are rare. Nevertheless, the trifocal IOL im- the defocus curves of the trifocal IOL group showed a plantation should be a good option to restore wide range more continuous performance at the intermediate range visual acuity well for the cataract patients with previous under photopic and mesopic conditions. In the defocus corneal refractive laser surgery for myopia. curve of our study, the curve transited smoothly in the range between the peaks with defocus of 0.00 D and − Conclusions 3.00 D and reached the bottom as 0.14 logMAR at − In conclusion, the trifocal intraocular lens can safely 2.50 D. Besides the defocus of 1.50 D (with a mean vis- provide a full range of adequate vision and accurate re- ual acuity of 0.34 logMAR), all visual acuities tested at fractive outcomes for cataract patients after myopic other defocus diopters were better than 0.23 logMAR, excimer laser correction. The high spectacle independ- maintaining a functional range of visual acuity. These re- ence rate affords the patients a high satisfaction. Only sults further demonstrate the good and wide range visual few side effects such as halos and glare were observed outcomes of trifocal IOL implantation after previous and are possibly caused by extremely high myopia in few corneal refractive laser surgery for myopia. of the patients. In terms of the questionnaires survey, three patients (19%) reported halos and glare in postoperative 3 Abbreviations IOL: Intraocular lens; UDVA: Uncorrected distance visual acuity; months, while no patient reported flare. Two of these UIVA: Uncorrected intermediate visual acuity; UNVA: Uncorrected near visual three patients needed to use spectacles to read small acuity; LASIK: Laser in situ keratomileusis; PRK: Photorefractive keratectomy; print or a newspaper or book or to do some handwork. SE: Spherical equivalent; D: Diopter; SD: Standard deviation; logMAR: Logarithm of the minimal angle of resolution; CDVA: Corrected Looking back on the preoperative parameters of the two distance visual acuity; OCT: Optical coherence tomography; IOP: Intraocular patients, both of their surgery eyes were with high pressure Li et al. BMC Ophthalmology (2020) 20:293 Page 8 of 9

Acknowledgements 7. Li S, Jie Y. Cataract surgery and lens implantation. Curr Opin Ophthalmol. Not Applicable. 2019;30(1):39–43. 8. Fernandez-Vega L, Madrid-Costa D, Alfonso JF, Montes-Mico R, Poo-Lopez A. Authors’ contributions Optical and visual performance of diffractive intraocular lens implantation Both QML and FW contributed equally to this work. SWL and KS conceived after myopic laser in situ keratomileusis. J Cataract Refract Surg. 2009;35(5): of and designed this study. SWL, ZMW, ZL, CZ, BHC, JS performed the 825–32. surgeries and contributed to the data acquisition. QML performed the 9. Muftuoglu O, Dao L, Mootha VV, Verity SM, Bowman RW, Cavanagh HD, patient follow-up and data collection. QML and FW conducted independ- McCulley JP. Apodized diffractive intraocular lens implantation after laser in ently the data analysis and rechecking. FW drafted the initial manuscript. FW, situ keratomileusis with or without subsequent excimer laser enhancement. SWL and KS revised the manuscript critically for important intellectual con- J Cataract Refract Surg. 2010;36(11):1815–21. tent. This manuscript has been read and approved by all the authors and 10. Vrijman V, van der Linden JW, van der Meulen IJE, Mourits MP, Lapid- each author believes that the manuscript represents honest work. Gortzak R. Multifocal intraocular lens implantation after previous corneal refractive laser surgery for myopia. J Cataract Refract Surg. 2017;43(7):909– Funding 14. This study was supported by Aier Eye Hospital Group Scientific Research 11. Chang JS, Ng JC, Chan VK, Law AK. Visual outcomes, quality of vision, and Project Grant [no. AF152D01], Changsha, China. The funding bodies had no quality of life of diffractive multifocal intraocular lens implantation after role in the design of the study and collection, analysis, and interpretation myopic laser in situ keratomileusis: a prospective, observational case series. J and data and in the writing of the manuscript. Ophthalmol. 2017;2017:6459504. 12. Vryghem JC, Heireman S. Visual performance after the implantation of a new trifocal intraocular lens. Clin Ophthalmol. 2013;7:1957–65. Availability of data and materials 13. Jonker SM, Bauer NJ, Makhotkina NY, Berendschot TT, van den Biggelaar FJ, The analytic data used to support the findings of this study are included Nuijts RM. Comparison of a trifocal intraocular lens with a +3.0 D bifocal within the article. Other original data used to support the findings of this IOL: results of a prospective randomized clinical trial. J Cataract Refract Surg. study are available from the corresponding author upon request. 2015;41(8):1631–40. 14. Mojzis P, Kukuckova L, Majerova K, Liehneova K, Pinero DP. Comparative Ethics approval and consent to participate analysis of the visual performance after cataract surgery with implantation Ethics Committee approval by the Institutional Review Board of the Aier of a bifocal or trifocal diffractive IOL. J Refract Surg. 2014;30(10):666–72. School of Ophthalmology of Central South University was obtained for the 15. Plaza-Puche AB, Alio JL. Analysis of defocus curves of different modern present study protocol that adhered to the tenets of the Declaration of multifocal intraocular lenses. Eur J Ophthalmol. 2016;26(5):412–7. Helsinki. Written informed consents were obtained from all the enrolled 16. Plaza-Puche AB, Alio JL, Sala E, Mojzis P. Impact of low mesopic contrast patients. sensitivity outcomes in different types of modern multifocal intraocular lenses. Eur J Ophthalmol. 2016;26(6):612–7. Consent for publication 17. Shen Z, Lin Y, Zhu Y, Liu X, Yan J, Yao K. Clinical comparison of patient Not Applicable. outcomes following implantation of trifocal or bifocal intraocular lenses: a systematic review and meta-analysis. Sci Rep. 2017;7:45337. Competing interests 18. Xu ZQ, Cao DM, Chen X, Wu S, Wang X, Wu Q. Comparison of clinical The authors declare that they have no conflicts of interest. performance between trifocal and bifocal intraocular lenses: a meta-analysis. PLoS One. 2017;12(10):e0186522. Author details 19. Wang W, Ni S, Li X, Chen X, Zhu Y, Xu W. Femtosecond laser-assisted 1Beijing Aier-Intech Eye Hospital, Beijing 100021, China. 2Department of cataract surgery with implantation of a diffractive trifocal intraocular lens after Ophthalmology, Aier School of Ophthalmology, Central South University, laser in situ keratomileusis: a case report. BMC Ophthalmol. 2018;18(1):160. Changsha 410083, China. 3Department of Ophthalmology, 20. Chow SSW, Chan TCY, Ng ALK, Kwok AKH. Outcomes of - Justus-Liebig-University, 35385 Giessen, Germany. 4Guangzhou Aier Eye correcting intraocular lenses after laser in situ keratomileusis. Int Hospital, Guangzhou 510260, China. 5Chongqing Aier Eye Hospital, Ophthalmol. 2019;39(5):1199–204. Chongqing 400020, China. 6Wanzhou Aier Eye Hospital, Chongqing 404000, 21. Steinberg EP, Tielsch JM, Schein OD, Javitt JC, Sharkey P, Cassard SD, Legro China. 7Shenzhen Aier Eye Hospital, Shenzhen 518005, China. MW, Diener-West M, Bass EB, Damiano AM, et al. The VF-14. An index of functional impairment in patients with cataract. Arch Ophthalmol. 1994; Received: 5 May 2020 Accepted: 6 July 2020 112(5):630–8. 22. Alonso J, Espallargues M, Andersen TF, Cassard SD, Dunn E, Bernth-Petersen P, Norregaard JC, Black C, Steinberg EP, Anderson GF. International References applicability of the VF-14. An index of visual function in patients with 1. Iijima K, Kamiya K, Shimizu K, Igarashi A, Komatsu M. Demographics of . Ophthalmology. 1997;104(5):799–807. patients having cataract surgery after laser in situ keratomileusis. J Cataract 23. Khadka J, Huang J, Mollazadegan K, Gao R, Chen H, Zhang S, Wang Q, Refract Surg. 2015;41(2):334–8. Pesudovs K. Translation, cultural adaptation, and Rasch analysis of the visual 2. Yoshino M, Bissen-Miyajima H, Minami K, Taira Y. Five-year postoperative function (VF-14) questionnaire. Invest Ophthalmol Vis Sci. 2014;55(7):4413–20. outcomes of apodized diffractive multifocal intraocular lens implantation. 24. Song X, Liu X, Wang W, Zhu Y, Qin Z, Lyu D, Shentu X, Xv W, Chen P, Ke Y. Jpn J Ophthalmol. 2013;57:510–3. Visual outcome and optical quality after implantation of zonal refractive 3. van der Linden JW, van der Meulen IJ, Mourits MP, Lapid-Gortzak R. multifocal and extended-range-of-vision IOLs: a prospective comparison. J Comparison of a hydrophilic and a hydrophobic apodized diffractive Cataract Refract Surg. 2020;46(4):540–8. multifocal intraocular lens. Int Ophthalmol. 2013;33(5):493–500. 25. Haigis W. Intraocular lens calculation after refractive surgery for myopia: 4. de Vries NE, Webers CA, Montes-Mico R, Tahzib NG, Cheng YY, de Haigis-L formula. J Cataract Refract Surg. 2008;34(10):1658–63. Brabander J, Hendrikse F, Nuijts RM. Long-term follow-up of a multifocal 26. Abulafia A, Hill WE, Koch DD, Wang L, Barrett GD. Accuracy of the Barrett apodized diffractive intraocular lens after cataract surgery. J Cataract Refract true-K formula for intraocular lens power prediction after laser in situ Surg. 2008;34(9):1476–82. keratomileusis or photorefractive keratectomy for myopia. J Cataract Refract 5. Rosen E, Alio JL, Dick HB, Dell S, Slade S. Efficacy and safety of multifocal Surg. 2016;42(3):363–9. intraocular lenses following cataract and refractive lens exchange: 27. Shammas HJ, Shammas MC. No-history method of intraocular lens power Metaanalysis of peer-reviewed publications. J Cataract Refract Surg. 2016; calculation for cataract surgery after myopic laser in situ keratomileusis. J 42(2):310–28. Cataract Refract Surg. 2007;33(1):31–6. 6. Liu X, Xie L, Huang Y. Comparison of the visual performance after 28. Savini G, Bedei A, Barboni P, Ducoli P, Hoffer KJ. Intraocular lens power implantation of bifocal and trifocal intraocular lenses having an identical calculation by ray-tracing after myopic excimer laser surgery. Am J platform. J Refract Surg. 2018;34(4):273–80. Ophthalmol. 2014;157(1):150–3. Li et al. BMC Ophthalmology (2020) 20:293 Page 9 of 9

29. Mackool RJ, Ko W, Mackool R. Intraocular lens power calculation after laser in situ keratomileusis: Aphakic refraction technique. J Cataract Refract Surg. 2006;32(3):435–7. 30. Wang L, Hill WE, Koch DD. Evaluation of intraocular lens power prediction methods using the American Society of Cataract and Refractive Surgeons Post-Keratorefractive Intraocular Lens Power Calculator. J Cataract Refract Surg. 2010;36(9):1466–73. 31. Wang L, Tang M, Huang D, Weikert MP, Koch DD. Comparison of newer intraocular lens power calculation methods for eyes after corneal refractive surgery. Ophthalmology. 2015;122(12):2443–9. 32. McCarthy M, Gavanski GM, Paton KE, Holland SP. Intraocular lens power calculations after myopic laser refractive surgery: a comparison of methods in 173 eyes. Ophthalmology. 2011;118(5):940–4. 33. Mojzis P, Majerova K, Hrckova L, Pinero DP. Implantation of a diffractive trifocal intraocular lens: one-year follow-up. J Cataract Refract Surg. 2015; 41(8):1623–30. 34. Kohnen T, Titke C, Bohm M. Trifocal intraocular lens implantation to treat visual demands in various distances following lens removal. Am J Ophthalmol. 2016;161:71–7. 35. Seitz B, Langenbucher A, Nguyen NX, Kus MM, Kuchle M. Underestimation of intraocular lens power for cataract surgery after myopic photorefractive keratectomy. Ophthalmology. 1999;106(4):693–702. 36. Chan TC, Liu D, Yu M, Jhanji V. Longitudinal evaluation of posterior corneal elevation after laser refractive surgery using swept-source optical coherence tomography. Ophthalmology. 2015;122(4):687–92. 37. Chen X, Yuan F, Wu L. Metaanalysis of intraocular lens power calculation after laser refractive surgery in myopic eyes. J Cataract Refract Surg. 2016; 42(1):163–70. 38. Savini G, Hoffer KJ. Intraocular lens power calculation in eyes with previous corneal refractive surgery. Eye Vis (Lond). 2018;5:18. 39. Saiki M, Negishi K, Kato N, Torii H, Dogru M, Tsubota K. Ray tracing software for intraocular lens power calculation after corneal excimer laser surgery. Jpn J Ophthalmol. 2014;58(3):276–81. 40. Hoffer KJ. Intraocular lens power calculation after previous laser refractive surgery. J Cataract Refract Surg. 2009;35(4):759–65. 41. Yu ZX, Li SW, Huo DM, Xu M, Shi S, Liu C, Zhao R. Evaluation of the accuracy of Sirius ray-tracing method for IOL power calculation in post- corneal-refractive-surgery eyes. Ophthalmol CHN. 2019;28(2):98–103.

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